Aims

Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems.

The use of cannabis is increasingly medically relevant as it is legalized and gains acceptance more broadly. However, the effects of marijuana use on postoperative outcomes following orthopedic surgery have not been well-characterized. This study seeks to illuminate the relationship between marijuana use and the incidence postoperative complications including: DVT, PE, nonunion, and infection following common orthopedic procedures. This study was conducted using a national orthopaedic claims insurance database. We identified all patients undergoing knee arthroscopy, shoulder arthroscopy, operatively managed long bone fractures (humerus, femur, tibia and/or fibula, and radius and/or ulna), and single-level lumbar fusion. The proportion of patients within each surgery cohort who had a diagnostic code for marijuana dependence was assessed. The rates of DVT, PE, and infection within 90 days were assessed for all patients. The rate of nonunion was assessed for the long bone fracture and lumbar fusion cohorts. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities. We identified 1,113,944 knee arthroscopy, 747,938 shoulder arthroscopy, 88,891 lumbar fusion, and 37,163 long bone fracture patients. Out of the 1,987,936 patients, 24,404 patients had a diagnostic code for marijuana dependence. Within all four surgical subgroups, the marijuana dependence cohort experienced increased rates of infection, PE, and DVT, as well as increased rates of nonunion in the lumbar fusion and long bone fracture populations. In the multivariate analyses controlling for a variety of patient risk factors including tobacco use, marijuana dependence was identified as an independent risk factor for infection within all four surgical subgroups (Knee: OR 1.85, p < 0.001; Shoulder: OR 1.65, p < 0.001; Spine: OR 1.45, p < 0.001; Long bone: OR 1.28, p < 0.001), and for nonunion in the lumbar fusion (OR 1.38, p < 0.001) and long bone fracture (OR 1.31, p < 0.001) subgroups. Our data suggests that marijuana dependence may be associated with increased rates of infection and nonunion following a variety of orthopaedic procedures. During preoperative evaluation, surgeons may consider marijuana use as a potential risk factor for postoperative complications, especially within the context of marijuana legalization. Future research into this relationship is necessary

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Complex proximal humerus fractures account for 10% of fractures in patients over 65 years of age. With the emergence of new implants, there is growing trend towards surgical management of these types of fractures, despite the lack of clinical evidence of its superiority over a conservative option. Orthopaedic surgeons' perception plays a large role in the surgical decision making for complex proximal humerus fractures in the elderly. No studies have been conducted to date to examine factors that influence the surgical decision-making in orthopaedic surgeons in regards to these types of fractures. A self-administered questionnaire was sent to orthopaedic surgeons. It included demographic questions as well as clinical vignettes assessing the risk / benefit perception of orthopaedic surgeons in different situations. Orthopaedic surgeons self-reported the proportion of proximal humerus fractures that were treated surgically in patients during the last year. Univariate analyzes were conducted to identify the factors that influenced the operation rates. A total of 127 orthopaedic surgeons completed the questionnaire. The response rate was 37%. The risk / benefit perception of surgical management varied according to the type of practice, year of training, operation rate as well as the ease of the surgeon in performing shoulder procedures (p < 0.05). According to the queried surgeons, the most important factors affecting their decision-making were patient's age, the type of fracture, co-morbidities, level of independence and potential for rehabilitation. The type of surgery proposed varied depending on the training and familiarity of the surgeon with the procedure. The risk / benefit perception of orthopaedic surgeons regarding surgical treatment of proximal humerus fractures in elderly patients appears to vary widely. The decision to opt for surgical management is influenced by the surgeon's familiarity with the procedure, their year of training and their subspecialty. This study demonstrates the need to establish a decision-making tool to assist orthopaedic surgeons and patients with this clinical decision

Introduction. Positive expectations can increase compliance with treatment and realistic expectations may reduce postoperative dissatisfaction. Recently there are articles regarding expectations of patients from their TKA in western literature and only few articles based on Korean populations which don't encompass the whole spectrum of expectations in Korean patients. In all those articles based on pre-operative expectation, results were applied to whole expectation category uniformly not differentially. We aimed to document the pre-operative expectations in Korean patients undergoing total knee replacement using an established survey form and to determine whether expectations were influenced by socio-demographic factors and socio-demographic factors influences expectation items in particular category uniformly or differentially. Methods. Expectations regarding 19 items in the Knee Replacement Expectation Survey form were investigated in 228 patients scheduled for total knee replacement. The levels and distribution patterns of individual and summated expectation of five expectation categories; relief from pain, baseline activity, high flexion activity, social activity and psychological wellbeing, constructed from the 19 items were assessed. Univariate analyses and Binary logistic regression were performed and analyzed to examine the association of expectations with the socio-demographic factors. Results. The top five expectations among individual items were: improvement in walking ability, relief from pain, ascending and descending stairs, improvement in changing position and improvement in daily activity, respectively. Among the five expectation categories, relief from pain was ranked the highest, followed by restoration of baseline activity, ability to perform high flexion activities, psychological well-being and ability to participate in social activities respectively. Conclusion. There was a high expectation of restoration of walking ability, relief from pain and high flexion activity, whereas the expectation was more variable for psychological well-being and social activities. An age of < 65years, being employed, male gender, previous participation in high level sports activity, less income were all found to be significantly associated with higher expectations in social activity category whereas in baseline category, pain relief category and psychological well being category there are no significantly associated socio-demographic factors found, which shows these are the expectation items/categories which don't depend on socio-demographic factors and are highly expected by all patients undergoing TKA in our study. We also found that Socio-demographic factors influence individual expectation items in particular category differentially not uniformly hence results of individual items don't reflect the whole category or vice versa

Background The minimum size required for a successful quadrupled hamstring autograft ACL reconstruction remains controversial. The risks of ACL re-tear in younger patients who tend to participate in a higher level of sports activity, and female athletes who have numerous predisposing factors, are poorly defined. Purpose To identify risk factors for graft re-tears within 2 years of ACL surgery. The hypotheses are that female sex, a smaller size graft, and younger patients will increase the odds of failure. Study Design Cohort Study. Level of evidence, 3. A cohort of 503 athletes undergoing primary, autograft hamstring ACL reconstruction, performed by a single surgeon using the same surgical technique and rehabilitation protocol, between September-December 2012, was followed for a total duration of 2 years. Return to play was allowed between 6 and 12 months post-surgery upon completion of functional testing. Exclusion criteria included infections, revisions, double bundle techniques, multi-ligament injuries, non-compliance, BTB/allografts/hybrid grafts. Primary outcome consisted of binary data (ACL graft re-tear or no tear) as measured on physical exam (Lachman and pivot shift) and MRI. Multivariate logistic regression statistical analysis with model fitting was used to investigate the predictive value of sex, age, and graft size on ACL re-tear. Secondary sensitivity analyses were performed on the adolescent subgroup, age and graft size as categorical variables, and testing for interactions among variables. Sample size was calculated based on the rule of 10 events per independent variable for logistic regression. The mean age of the 503 athletes was 27.5 (SD 10.6; range = 12–61). There were 235 females (47%) and 268 males (53%) with a 6 % rate of re-tears (28 patients; 17 females). Mean graft size was 7.9 (SD 0.6; range = 6–10). Univariate analyses of graft size, sex, and age only in the model showed that younger age (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80–0.93; P = .001] and smaller graft size (OR = 0.36; 95% CI = 0.18–0.70; P = .003) were significantly predictive of re-tear. Female sex was correlated with re-tear but was not significant (OR = 1.8; 95% CI = 0.84–3.97; P = .13). Multivariate analysis with all 3 variables in the model showed similar significant results. Graft size < 8 mm (OR = 2.95; 95% CI = 1.33–6.53; P = .008) and age < 25 (OR = 7.01; 95% CI = 2.40–20.53; P = .001) were significantly predictive of re-tear. Entire model was statistically significant (Omnibus test P = .001; Hosmer-Lemeshow statistic P = .68; Receiver Operating Curve [ROC] = 0.8). Surgeons should counsel their patients who are female, younger than 25 and with a graft size less than 8 mm accordingly and consider modifying their surgical or rehabilitation techniques to mitigate these re-tear risks

Background. Two-stage revision is considered the gold standard for treatment of knee prosthetic joint infections. Current guidelines for selecting the most appropriate procedure to eradicate knee prosthetic joint infections are based upon the duration of symptoms, the condition of the implant and soft tissue evaluated during surgery and the infecting organism. A more robust tool to identify candidates for two-stage revision and who are at high risk for treatment failure might improve preoperative risk assessment and increase a surgeon's index of suspicion, resulting in closer monitoring, optimization of risk factors for failure and more aggressive management of those patients who are predicted to fail. Methods. Charts from 3,809 revision total joint arthroplasties were reviewed. Demographic data, clinical data and disease follow-up on 314 patients with infected total knee arthroplasty treated with two-stage revision were collected. Univariate analyses were performed to determine which variables were independently associated with failure of the procedure to eradicate the prosthetic joint infections. Cox regression was used to construct a model predicting the probability of treatment failure and the results were used to generate a nomogram which was internally validated using bootstrapping. Results. 209 (66.6%) cases experienced reinfection at an average of 429 days (range, 9 to 3,886) following the two-stage revision. Univariate analysis identified multiple variables independently associated with reinfection including: a longer duration of symptoms (p<0.001), a longer time from the index total knee arthroplasty (p=0.003), a higher number of previous surgeries in the same joint (p<0.001), an elevated C-reactive protein (p=0.005), an elevated erythrocyte sedimentation rate (p=0.006), a low hemoglobin (p=0.001), a previous infection in the same joint (p<0.001), diabetes (p<0.001), and heart disease (p=0.006). Among 1,000 bootstrap samples, the bias corrected receiver operating characteristic for the nomogram was 0.77. Conclusions. Preoperative knowledge of the probability that a treatment strategy will eradicate a patient's prosthetic joint infection may improve risk assessment and allow adequate time for consideration of alternative therapies

To identify factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit. There is a paucity of information on factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit. Patients were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). VOTOR includes all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria, Australia. Patient-reported outcomes and data on possible predictive factors, including demographic details, injury-related and treatment-based factors, were obtained from the VOTOR database. Patient-reported outcomes were measured at 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12), a Numerical Rating Scale (NRS) for pain, global outcome questions and data was collected on return to work or study. For the identification of predictive factors, univariate analyses of outcome vs. each predictor were carried out first, followed by logistic multiple regression. 344 patients were eligible for the study and data were obtained for 264 (76.7%) patients at 12 months follow-up. Patients reported ongoing pain at 12 months post-injury (moderate–severe: 33.5%), disability (70.1%) and inability to return to work or study (23.3%). A number of demographic, injury-related and treatment-based factors were identified as being predictive of poor patient-reported outcomes. Patients who had associated radius fracture(s) were more likely to have moderate to severe disability (odds ratio (OR) = 3.85, 95% confidence interval = 1.30–11.39), a poorer physical health status (OR = 3.73, 1.37–10.12) and moderate to severe pain (OR = 3.23, 1.22–8.56) at 12 months post-injury than patients without radius fracture. Patients who did not receive compensation for work-related or road traffic-related injuries were less likely to report moderate to severe pain (OR = 0.45, 0.23–0.90) or have a poorer mental health status (OR = 0.17, 0.04–0.70) at 12 months post-injury than those who received compensation. The prognostic factors identified in this study may assist clinicians in the identification of patients requiring more intensive follow-up or additional rehabilitation to ultimately improve patient care

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.